HospitalInspections.org

Based on interview and record review of 35 personnel files the facility failed to comply with Missouri State Law by not performing Electronic Disqualification List (EDL) checks after initial hire to ensure that facility employees had not been previously identified as perpetrators for abuse or neglect in the health care system for 5,396 of 5,396 employees. The facility had a census of 345.
Findings included:
1. Record review on 01/20/11 of employee personnel files showed no documentation for EDL checks on the employees after the date of hire for the 35 employee personnel files reviewed.
During an interview on 01/20/11 at 1:22 PM, with Staff LLL, Director of Human Relations stated the EDL checks were completed but documentation was not kept in the individual personnel files.
2. During an interview on 01/24/11 at 1:00 PM, with Staff LLL, and Staff MMM, Chief of Human Relations recanted the previous statements and explained that EDL checks were completed before hiring employees, but were never completed after that time. Staff MMM stated he/she was unaware that this was required by Missouri State Law no less than annually and periodically on all employees as long as the employee is working at the facility.

Based on observation, record review, policy review, and interviews the facility failed to:
-ensure patients were provided care in a safe setting for 16 of 24 patients on unit 3 South and 11 of 21 patients on unit 2 South by allowing patients access to the following:
-bathtubs with non-suicide resistant water control knobs and faucets
-non-suicide resistant plumbing fixtures and exposed pipes connecting toilets to bathroom walls
-shower water control knobs which provide potential looping hazards
-showers with a metal piece protruding from the shower walls
-sinks with non-suicide resistant plumbing fixtures
-toilet stall doors, which provide potential looping hazards(A0144)
The facility admits patients with suicidal ideations, history of suicidal ideations, attempts to harm self or others and patients with assaultive tendencies.
-provide patient safety by using handcuffs on patients as a form of restraint (A0154)
-ensure patients and visitors were provided full disclosure of video recording in the Sleep Laboratory located at the University Hospital and in the Emergency Department at the University Hospital (A0143)
-ensure personal privacy for eight of eight patients on the pediatric unit by allowing windows without coverings in all patient doors (A143)
-failed to require hemodialysis (commonly referred to as dialysis and is a medical process that is used when a person's kidneys are damaged and can no longer filter toxins from the blood using a machine that pumps blood out of the patient, through a filtering machine and back into the patient) access ports to be visible and educate the patients as to the imminent risk of death if the ports were compromised when dialyzing (a patient can bleed out [pump the blood out of the body completely] in one minute) (A0144)
- and failed to form a plan specific to the Newborn Intensive Care Unit (NICU) for the evacuation of babies from the building and failed to ensure the staff is educated in the appropriate procedure to protect the safety of the patients of the NICU if evacuation is necessary. This puts all infants and children at risk for harm.
The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with CFR 482.13, Condition of Participation: Patient Rights.

The facility had a census of 345.

Based on observation, interview, and record review, the facility failed to ensure two patient's (#67 and #72) out of two patients in the outpatient and Emergency Department (ED)setting, were informed of their patient rights prior to treatment. The census at the time of the survey was eight (four patients in the Urgent Care Center and four patients in the Women's and Children's ED).

Findings included:

Record review of Policy #RI-8, titled "Patient's Rights and Responsibilities", dated 02/12/09 (without further revision) showed that patient rights are required at the time of admission to the hospital. The policy further reveals that hospital staff are to inform each patient, legal guardian, legally appointed surrogate decision-maker, verbally or by means of the Patient Information Booklet of his/her rights (#2, page 3 of 4).

Observation on 01/21/11 at 10:25 AM, of the University Hospital Urgent Care Center showed Staff FFFF, Urgent Care Manager, picked up and moved a standing picture frame from a counter (approximately three feet beyond the registration window) to the registration window. The picture frame contained patient rights information.

During an interview on 01/21/11 at 10:25 AM, Staff GGGG, Patient Service Representative stated that patient rights are not given to or reviewed with patients in the Urgent Care Center, but are posted in a frame.

During an interview on 01/21/11 at 10:50 AM, Patient #72 stated that he/she did not receive patient rights information during registration. Patient #72's family member (who accompanied the patient during registration), also stated that no patient rights were provided to Patient #72, or the family member. Patient #72 did not know what patient rights meant, and did not recognize a copy of the patient rights (copied from the picture frame) when provided to the patient and family member.

During an interview on 01/25/11 at 8:55 AM, Staff LLLL, Admissions Representative of the Women's and Children's Hospital ED stated that the only time patients are informed of their rights is on their first visit to the ED, when a laminated copy of the patient rights is placed in front of them to read, or when they are admitted to the hospital. Staff LLLL stated that if a patient visited the ED five years ago and was informed of the patient rights at that time (reflected by an electronic signature), registration staff does not inform the patient of their rights again upon return visits.

Observation on 01/25/11 at 8:55 AM, of an ED registration booklet showed a laminated copy of patient rights inside.

During an interview on 01/25/11 at 9:25 AM, family member of Patient #67 (minor) stated that the patient had been to Women's and Children's Hospital many times previously, and had been in the ED for approximately 30 minutes during this visit. The family member stated he/she had not received patient rights information during the registration process for the current visit, did not know what patient rights were, and did not recognize a copy of the patient rights (copied from the registration booklet) when provided to the family member.

Based on policy review, observation and interview the facility failed to ensure patients were provided full disclosure of video recording by six cameras located in six sleep rooms in the Sleep Laboratory (Sleep Lab) located at the University Hospital; in four of four trauma bays in the Emergency Department (ED) at the University Hospital, and the facility failed to ensure personal privacy for eight of eight patients on the psychiatric services adolescent unit by allowing windows without coverings in all patient doors. The facility had a census of 345. The Sleep Lab had a census of 0, the ED had a census of 20 and the pediatric unit had a census of eight.

Findings included:

1. Record review of Policy #RI-2 titled, "Photographs or Recordings of Patients", dated 02/12/08 (without further revision) showed the objective of the policy was to provide a procedure for protecting the privacy of patients from unwarranted invasion while honoring legitimate, authorized requests for videotaping. The policy also showed the following general information (in part):
- A patient must provide written informed consent to photographs or recordings for any purpose including identification, diagnosis and treatment (page 1 of 4),
- Patients may be photographed or recorded only after a "Patient Photo and Recording Release" (form MR 232-11-84 attached to the policy) has been signed by the patient and witnessed (# 10, page 1 or 4),
- In case of patients less than 18 years of age, or a patient who has a guardian, the release form must be signed by a parent or the legal guardian (#11, page 1 of 4),
- Permission by fax or letter may be considered binding if it contains the information that is on the Photo and Recording release form (MR 232-11-84) (#12, page 1 of 4),
- A "Patient Photo Release will have to be signed by a physician, and it will be his/her responsibility to secure a properly executed release as soon as possible (#13, page 1 of 4),
- It is the responsibility of the patient's physician to secure the properly signed Release and to have it in the patient's permanent records (#15, page 2 of 4).
The policy also showed the following procedure (in part):
- The requestor must obtain permission and consent from the patient or legal surrogate after fully informing them as to the purpose and intended use of these recordings (#1B, page 2 of 4);
- Nursing personnel must have the patient or representative sign "Photo and Recording Release" giving written authorization (#3A, page 2 of 4);
-nursing personnel must file the form in patient's medical record (#3B, page 2 of 4).

Observation on 01/14/11 at 3:30 PM, in the Sleep Lab showed six sleep rooms with ceiling mounted video cameras used to record patients while they are sleeping to complete a sleep study. Further observation of the Sleep Lab showed no signage in the lab/unit or in the six sleep rooms indicating to a patient they are being videotaped. There were no patients in the Sleep Lab at that time.

During an interview on 01/14/11 at 3:30 PM, and on 01/21/11 at 1:35 PM, Staff B, Manager of the Sleep Lab stated the following:
- There is no signage in the lab/unit or in the sleep rooms to inform patients they are being videotaped,
- Videocameras are used to record sleep studies,
- Patients are informed verbally by staff that they will be videotaped prior to the sleep study,
- Information is sent by mail to patients prior to the sleep study which includes a statement stating the Sleep Lab uses video monitoring and recording during the sleep study,
- Staff attempt to contact the patient one week prior to the sleep study to ensure they received the information and answer any questions patients may have,
- Patients do not sign a consent form to be videotaped prior to the sleep study.






29047

2. During an interview on 01/18/11 at 2:00 PM, Staff RRRR, ED Registered Nurse (RN) stated that the ED has patient rooms which are video monitored and recorded.
Observation on 01/18/11 at 2:35 PM, of the University Hospital's ED showed Trauma Room three and four (only two of the four trauma rooms were observed) contained a dome camera in the corner of each room, where the wall meets the ceiling. The dome is tinted and therefore does not reveal the camera behind the dome. Further observation of the rooms showed no signage indicating to a patient they are being videotaped, and no on-off switch which allows staff to control when the video monitoring/recording occurs. This prevents patient privacy while undressing or toileting, during invasive procedures, as well as during physical examinations.
During an interview on 01/18/11 at 2:35 PM, Staff YYY, ED Assistant Manager stated that the trauma rooms are used for trauma patients as well as non-trauma patients, and that any patients placed in the trauma bays are recorded, since the cameras cannot be shut off.
During an interview on 01/18/11 at 2:40 PM, Staff AAAA, Trauma Program Manager stated that the cameras in the ED trauma bays are used for monitoring trauma patients and the trauma process for improvements in care, "but we don't advertise it". Staff AAAA stated that there are no signs in the patient rooms indicating the patients are being video monitored or recorded. Staff AAAA stated that the only staff who have access to the security monitors and recordings are Security, Staff AAAA, and the Trauma Medical Director. Staff AAAA also stated that the tapes are only reviewed for Trauma process, but when looking for a specific trauma patient, other patients and their care could be viewed during the scanning process.
During an interview on 01/19/11 at 3:30 PM, Staff AAAA stated that the cameras in the four trauma bays record patients continually. Staff AAAA stated that the recording equipment is in a locked room and only two staff members have access to the recordings. Staff AAAA said, "We don't inform any patients they are being taped."








19957

3. Review of facility policy titled "Patient's Rights and Responsibilities" revised 02/12/09 showed (in part) under Patient Rights #2 that patients have the right to personal privacy concerning medical care and clinical records.

Observation on 01/20/11 at 3:27 PM, on One South, the behavioral health pediatric unit at University Hospital, showed one private patient room and six patient rooms with two beds each. The unit had a census of eight. All doors to the patient rooms have a window approximately 10" by 10" in size. The facility has no window coverings over any of the seven patient door windows to allow for patient privacy. Any patient, staff member or hospital employee walking past the doors can see directly into the patient rooms.

During an interview on 01/20/11 at 3:30 PM, Staff F, the Director of Clinical Operations for Psychiatric Services, Staff F stated that patients are not allowed to change clothes in their rooms. Staff F stated that the facility installed the windows in the doors to provide for patient safety to allow staff to observe patients without entering the rooms.

Based on observation, interview, record review and review of facility policies, the facility failed to ensure patients admitted to University Hospital with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting for 16 of 24 patients on unit 3 South and 11 of 21 patients on unit 2 South by allowing patients access to the following:
-bathtubs with non-suicide resistant water control knobs and faucets
-non-suicide resistant plumbing fixtures and exposed pipes connecting toilets to bathroom walls
-shower water control knobs and showers with a metal piece protruding from the shower walls which provide potential looping hazards
-sinks with non-suicide resistant plumbing fixtures
-and interior toilet stall doors, which provide potential looping hazards.

The facility also failed to require hemodialysis (commonly referred to as dialysis and is a medical process used when a person's kidneys are damaged and can no longer filter toxins from the blood using a machine that pumps blood out of the patient, through a filtering machine and back into the patient) access ports to be visible and educate patients as to the imminent risk of death if the ports were compromised when dialyzing (a patient can bleed out [pump the blood out of the body completely] in one minute) for two of two dialysis patients (#74 and #75) .

The facility also failed to form a plan specific to the Newborn Intensive Care Unit (NICU) for the evacuation of babies from the building and failed to ensure the staff were educated in the appropriate procedure to protect the safety of the patients of the NICU if evacuation was necessary. This puts all infants and children at risk for harm. The census of the NICU was 12 and the facility had a census of 345.
Findings included:
1. Observation of the Psychiatric Services unit 3 South on 01/18/11 at 2:10 PM, and of Psychiatric Services unit 2 South at 3:35 PM, showed a hallway common bathroom for female patients. Observation showed the bathroom door unlocked. Observation inside the bathroom showed a bathtub with a central water control knob protruding from the wall approximately two inches and approximately two feet from the bottom of the tub floor and a faucet protruding from the tub approximately five inches and approximately 16 inches from the bottom of the tub floor.

Observation also showed a shower stall with a central water control knob protruding from the wall approximately three inches and approximately five feet off the floor. Also protruding from the shower wall is a piece of metal approximately three inches long and approximately three feet from the floor.

Observation showed two commodes with exposed pipes (plumbing) approximately two feet off the floor.

Observation showed two sinks with exposed pipes approximately three feet off the floor.

The configuration of these water control knobs and pipes expose plumbing objects that material or a device could be looped around for strangulation, which places all patients using the bathroom at risk.

Observation showed two toilet stall doors with openings at the tops and bottoms of the doors. There is also a wall partition dividing the two toilets. The dividing wall is open at the top. These doors and dividing wall create a situation where a ligature could be looped over the doors or dividing wall for hanging or strangulation.

Observation of the Psychiatric Services unit 3 South on 01/18/11 at 3:00 PM, and of Psychiatric Services unit 2 South at 3:50 PM, showed a hallway common bathroom for male patients. Observation showed the bathroom door unlocked. Observation inside the bathroom showed a bathtub with a central water control knob protruding from the wall approximately two inches and approximately two feet from the bottom of the tub floor and a faucet protruding from the tub approximately five inches and approximately 16 inches from the bottom of the tub floor.

Observation also showed two shower stalls with a central water control knob protruding from the wall approximately three inches and approximately five feet off the floor. Also protruding from the shower wall is a piece of metal approximately three inches long and approximately three feet from the floor.

Observation showed two commodes with exposed pipes (plumbing) approximately two feet off the floor and one urinal with a flush handle approximately three and one half feet from the floor.

Observation showed two sinks with exposed pipes approximately three feet off the floor.

During an interview on 01/18/11 at 2:50 PM, the Director of Clinical Operations for Psychiatric Services, Staff F stated that the patient rooms on the psychiatric units do not have bathrooms and patients use the common bathrooms located in the hallways. Staff F stated that the bathroom doors are not locked and patients can use the bathrooms without staff supervision. Staff F stated that the 3 South unit will continue to provide services to patients until August when the facility will close it for renovation. Staff F stated that the piece of metal protruding from the shower walls is an old fitting for a water mixing valve.

During an interview on 01/18/11 at 2:50 PM, Staff F stated that the facility admits patients with diagnoses of suicidal ideation, history of suicidal ideations or attempts at self harm.

Review of precaution status for patients on unit 3 South identified 16 of the current 24 patients on the unit are on suicide precautions.

Review of precaution status for patients on unit 2 South identified 11 of the current 21 patients on the unit are on suicide precautions.

During a meeting on 01/20/11 at 9:15 AM, with the facility leadership team, Executive Director of Psychiatric Services, Staff E stated that as of 3:00 PM, on 01/19/11 the facility locked the bathroom doors on 3 South and 2 South. Staff F stated that until the bathroom fixtures are renovated patients will need to ask staff to unlock the bathroom doors.




27029

2. Observation of the Dialysis unit on 01/24/11 at 2:00 PM, showed two Patients (#74 and #75) observed during their dialysis treatments. Patient's #74 and #75 were lying in beds and were completely covered with blankets and their access ports could not be visualized. Failure to visualize an access port during dialysis treatment puts the patient at imminent risk of death if the ports were compromised or dislodged because a patient can bleed out [pump the blood out of the body completely] in one minute.
During an interview on 01/24/11 at 2:05 PM, RN, Staff CCCCC, Director of the Dialysis Unit stated that the access ports were covered because Patient #74 was cold and Patient #75's access port was located in the groin area. Staff CCCCC then talked with Staff PPP, RN regarding the covered access sites. Staff PPP then told Patient #74 to uncover his/her access site because, "the State is here watching and he/she can't see your site".
Record review of the following "Dialysis Policies and Procedures": Structure Standards, Dialysis Services, number C-7 dated 07/19/2010; number C-8 dated 07/19/2010; number C-10 dated 07/19/2010 and C-25 dated 07/19/2010 did not address the need for dialysis access ports to be visualized during dialysis treatments.


27727

3. Review of facility policy titled, "Evacuation" showed in part the following information:
Mitigation:
The primary defense strategy to protect patient, visitors, and staff from significant peril is to defend them in place; and if necessary, to withdraw occupancy from any dangerous isolated event until such time that the area is safely recovered for patient use. Any degree of evacuation should be under the guidance of the Command Center at the earliest opportunity.

Purpose:
To provide staff with general guidance in the event it becomes necessary to evacuate and to help staff continue to deliver safe and appropriate care to patients during and after the evacuation. Each department is encouraged to develop specific contingencies applicable for their specific areas.

Definitions:
Vertical evacuation is the movement from one floor to another floor via the elevator or the stairwell. The elevator cannot be used in fire evacuations. This type of evacuation should only be attempted if absolutely necessary.

Equipment:
Equipment is available at inpatient facilities for vertical evacuation of patients.

Evacuation Routes
Vertical evacuation should be attempted only if necessary. Use elevators as directed by fire personnel, but have a predetermined area in mind to account for all patients and staff.
Vertical Routes
Once the decision to evacuate in a vertical fashion has been established and the route of evacuation determined, the bedside nurse will evaluate the well-being of the patient in performance of the following steps for pre-evacuation.
-Disconnect monitors, ensure that each assigned patient has an ID band on, and place all lines to saline/heparin lock, except those that are required to infuse drugs for cardiac/respiratory support.
-If vertical evacuation is necessary, staff, patients and visitors will meet on the main floor areas of a predetermined (by department) location so as to provide shelter for the patients until another area or facility has been established.

During an interview on 01/25/11 at 10:15 AM, Staff UU, Newborn Intensive Care Unit (NICU),RN stated that if there was a fire and the babies had to leave the hospital; the babies would be placed in aprons (an apron worn by the nurse which has large pockets in which the babies would be placed.) and carried down the stairs by a nurse. Staff UU stated he/she did not know where the aprons were kept and did not know where the babies would be taken after leaving the NICU.

During an interview on 01/25/11 at 10:20 AM, Staff VV, NICU-RN stated if the babies had to leave the building; the nurses would use the aprons. Staff VV stated he/she did not know where the aprons were stored.

During an interview on 01/25/11 at 10:25 AM, Staff TT, Manager of the NICU stated aprons had not been available for some time and the babies would be carried down the stairs by the nurses. The babies on ventilators (a machine designed to mechanically breath) would be left on the unit.

During an interview on 01/25/11 at 1:24 PM, Staff DD, Coordinator of Quality Improvement stated there was not a policy specific to evacuations for the NICU. Staff DD stated the current plan lacks specificity for dealing with the most critical neonates (newborn). Staff DD stated there was obviously a gap in the information to staff in evacuating the NICU regarding aprons.

Based on interview and record review, the facility failed to provide patient safety by using handcuffs on patients as a form of restraint. Nine patients were placed in handcuffs out of 248 security guard responses over a 12 month period. Three security reports (Patient #65, #66, and #76) were reviewed out of the nine handcuff occurrences reported. This had the potential to affect all patients restrained by security staff. The facility had a census of 345.
Findings included:
1. Review of Policy titled "Handcuff Policy" dated 08/97, with a revision date of 10/09, showed that if a person is causing a problem, in danger of harming himself or others, or is causing property damage, and no other restraint method is feasible, handcuffs are to be used, and can be used on a patient if exigent (immediate need for action) circumstances exist. Further review of the policy showed that handcuffs will be replaced with leather or polypropylene restraints as soon as feasible.
2. Record review of the hospital security report log for the previous 12 months showed nine patients were placed in handcuffs by University employed Security Guards.
3. During an interview on 01/24/11 at 1:00 PM, Staff TTTT, Director of Corporate Compliance stated that security staff are employed by the University Hospital Health System, and are not contracted employees.
During an interview on 01/21/11 at 9:10 AM, Staff EEEE, Director of Security stated that security uses handcuffs on patients when needed.
During an interview on 01/25/11 at 9:35 AM, Staff MMMM, Security Guard stated that he/she has placed a patient of the University Healthcare System in handcuffs before.
During an interview on 01/24/11 at 3:47 PM, Staff JJJJ, Security; Staff EEEE, Director of Security; and Staff KKKK, Security Operations stated law enforcement is not contacted when patients are placed in handcuffs unless it is something the security staff interprets as being prosecutable.
During an interview on 01/24/11 at 1:15 PM, Staff TTTT, stated that the hospital only uses handcuffs on patients until the patient is able to be placed in soft restraints, and then the handcuffs are removed.
Record review of a security report dated 11/23/10 at 12:31 PM, showed staff placed Patient #65 in four point soft restraints at 9:30 AM, after becoming combative and failing to follow instructions in the Emergency Department (ED). The patient was a "hold for psychiatric evaluation" and remained in soft restraints (one arm had been released to allow the patient to eat) until 12:27 PM, when security arrived to escort the patient to the admitted floor. Security placed the patient in handcuffs after the patient could not answer that he/she could keep his/her "thoughts gathered". The soft restraints were removed by the security guard, the patient was placed in a wheelchair by the security guard, and transported to the admitted floor without incident. The handcuffs were removed by the security guard after transporting the patient.
During an interview on 01/24/11 at 3:47 PM, Staff JJJJ, Security; Staff EEEE, Director of Security; and Staff KKKK, Security Operations stated that when Patient #65 was placed in handcuffs, after being restrained in soft restraints, that the use of handcuffs was appropriate for the transfer of a patient in a wheelchair to the admitted floor. Staff JJJJ, Staff EEEE, and Staff KKKK added that they do have the ability to transfer a patient on a cart, using soft restraints instead of handcuffs.
During an interview on 01/25/11 at 9:35 AM, Staff MMMM, Security Guard stated that placing Patient #65 in handcuffs after the patient was placed in soft restraints, was appropriate to transfer the patient to the admitted floor. Staff MMMM added that patients can be transferred on a cart while using soft restraints instead of handcuffs, and has been done in other cases.
4. Record review of a security report dated 02/11/10 at 10:09 AM, showed that Patient #66 was placed in handcuffs by security staff, after attempting to flee the hospital and refusing to return to his/her room.
Record review of a security report dated 08/16/10 at 7:08 AM, showed that Patient #76 was placed in handcuffs after attempting to flee the hospital and refusing to return to his/her room. The patient was under a 96 hour psychiatric hold for evaluation of mental health. Security guards placed the patient on the floor, handcuffed the patient, and took the patient back to his/her room.
5. During an interview on 01/24/11 at 1:15 PM, Staff TTTT, Director of Corporate Compliance stated that the regulation requirements under the State Operations Manual Standard A-0154 were interpreted as the security guards, employed by the hospital, met qualifications to apply handcuffs because the security guards had been trained in handcuff use.

Based on interview and record review, the facility failed to ensure a physicians order was obtained and documented for the use of restraints for three (Patient #23, #65, and #66) out of four patient records reviewed, who had been restrained by security. This had the potential to affect all patients. The facility had a census of 345.
Findings included:
1. Record review of Policy #PC-5-2, titled "Patient Restraint, Restrictive Practices, and Seclusion - Behavioral", dated 01/07/11 (without further revision), showed the definition of a behavioral management restraint was a restraint initiated in emergency or crisis situations if a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to his/her safety or that of others. The policy showed the following (in part):
-restraint restricts freedom of movement of the whole or a portion of the patient's body (#1, page 1 of 7);
-restraints covered in the policy include locked restraint devices (#3A, page 1 of 7);
-the restraint must be ordered by a physician or LIP who is responsible for the care of the patient (#10E, page 3 of 7);
-in an emergency, a trained Registered Nurse (RN) may initiate restraints, but a physician order must be immediately obtained (#9, page 2 of 7);
-the use of restraints must be ordered by a physician who is responsible for the care of the patient, who is monitoring the patient (#10E, page 3 of 7).

2. During an interview on 01/19/11 at 9:50 AM, Patient #23's family member stated that on the evening of 01/17/11, Patient #23 became very aggressive and out of control due to his/her recent head injury. Security responded and placed the patient's arms up behind his/her back (motioning hands were placed behind the back and pulled hands upward between elbows). The family member of Patient #23 stated that the Security Guards and patient moved to a corner at the end of the hall and during the movement, the patient struck his/her head on the wall. The family member stated the patient was begging to have his/her arms released while still being held by security and then stated he/she was going to vomit, which the Patient #23 did. The security guard then released the patient from the hold, and escorted the patient back to bed.

Record review of Patient #23's open medical record showed Staff IIII, Five East Registered Nurse (RN), documented on 01/18/11 at 12:00 AM, that the patient became confused and combative and was "restrained by security".

During a phone interview on 01/24/11 at 2:10 PM, Staff IIII stated that security responded on the evening of 01/17/11 to assist with Patient #23, after he/she became confused and combative. Staff IIII stated that security was able to "get on each arm" to restrain the patient. Staff IIII stated that the patient and security guards moved to a corner in the hall, and the patient was repeatedly saying, "give me my arms back", which the security guards eventually did. Staff IIII stated during the movement of the patient to the corner, the patient hit his/her head on the wall and stated that he/she was going to vomit, but did not. Staff IIII stated he/she received a physician order for nylon restraints for Patient #23, but did not request or receive a physician order for a physical hold restraint, Staff IIII did not know what a physical hold was.

During an interview on 01/25/11 at 9:35 AM, Staff MMMM and Staff NNNN, Security Guards, stated that they responded to assist with Patient #23 on 01/17/11, after he/she became confused and refused to get back into bed. Staff MMMM stated that the guards stood on each side of Patient #23 and each guard took hold of his/her arm (immediately above the elbow) and wrist (referred to as "Soft, open-hand, pressure point control tactic"). Staff MMMM stated the patient began a forward movement, and the patient's arms were pulled up behind his/her back (referred to as an escort position), to control the patient. The patient's momentum towards the wall, caused the patient to strike his/her head on the wall while the patient's arms remained restrained behind his/her back. Staff MMMM stated Patient #23 then requested his/her arms to be freed, and after the patient became compliant, one of his/her arms was released, then the other.

During an interview on 01/21/11 at 9:10 AM, Staff EEEE, Director of Security stated that when security uses force in the form of a restraint, "we" get an order from the doctor, which usually occurs through the nurse speaking with the doctor. Staff EEEE stated he/she is not sure who writes the order for the restraint.

During an interview on 01/19/11 at 10:55 AM, Staff DDDD, Five East Unit Educator stated that there was no order documented for security's use of a physical hold restraint on Patient #23. Staff DDDD stated that it was the responsibility of the Security Staff to obtain an order from the physician when security restrains a patient.

During an interview on 01/21/11 at 1:27 PM, Staff HHHH, Security Guard, stated that it was the responsibility of the nurse to obtain and document orders from a physician when any type of restraint is used on a patient.

During an interview on 01/25/11 at 9:35 AM, Staff MMMM, Security Guard, stated that a nurse is responsible for obtaining an order when wrist and leg restraints are used, that he/she was not aware that a physical hold restraint required a physician order, and that he/she did not think a physician should tell security when and how to respond to a patient involved in a security issue.

3. Review of a Security log for the previous 12 months showed that security guards restrained patients in a locking restraint on nine different occasions. Three random security reports pulled from the log, documented that all three patients were placed in a locking restraint device by security staff. Further review of the three patients closed medical records by Staff CC, Coordinator of Nursing Standards, showed that two patients (Patient #65 and #66) did not have a physicians order documented for the application of the locking restraint device.

During an interview on 01/25/11 at 1:25 PM, Staff DD, Coordinator of Quality Improvement confirmed that there were no physician restraint orders documented for the locking restraint device used by security on Patient's #65 and #66.

Based on policy review and interview the facility failed to have a policy documenting the training requirements for physicians in the use of restraint or seclusion. The facility had a census of 345.

Findings included:

Review of the facility restraint policies showed no policy addressing restraint or seclusion training requirements for physicians.

During an interview on 01/21/11 at approximately 2:00 PM, Staff CC, Coordinator of Nursing Standards stated that the facility does not have a policy addressing the training requirements for physicians regarding the use of restraint or seclusion.

Based on interview, the facility failed to ensure the Spoken and Sign Language Interpreter Service is measured and evaluated for services provided to non or limited-English speaking patients and/or patients with a hearing impairment and the facility failed to ensure the services are included in the facility Quality Assessment Performance Improvement program.

During an interview on 01/21/11 at 1:25 PM, the Language Services Coordinator, Staff OO stated that the facility provides interpreter services for 63 different languages and interpreter services for hearing impaired patients.

Staff OO stated that the Interpreter Service has no system or process in place to track aspects of performance for quality assurance.

Based on observation and interview the facility failed to maintain all areas in a clean and orderly manner. The facility census was 345.

Findings included:

Observations during a tour of the Women's and Children's facility, conducted on the morning and afternoon of 01/25/11, showed the following:

-Observation at 11:01 AM, showed the wooden door to patient room 4411 was cracked and splintered leaving a jagged edge.
-Observation at 11:10 AM, showed the wooden door to patient room 4431 was cracked and splintered leaving a jagged edge.
-Observation at 11:12 AM, showed the wooden door to patient room 4417 was cracked and splintered leaving a jagged edge.
-Observation at 2:31 PM, showed the wooden door to utility room 3347 E was cracked and splintered leaving a jagged edge.

Observations during a tour of the Psychiatric Center facility, conducted on the morning of 01/21/2011, showed the following:

-Observation at 10:00 AM, showed the wooden door to patient room 148 was cracked and splintered leaving a jagged edge.

At the time of each observation at both facilities Staff PPPP, Safety Coordinator confirmed the need for repair.

Based on review of the facility infection control manual, and observation, the facility failed to ensure staff followed proper hand hygiene procedure while administering medications to five (#1, #2, #25, #26, #8) of 13 patients observed for medication administration on the psychiatric services unit 3 South and/or providing wound care for five (#39,
#41, #49, #74 and #75) of five patients observed. The facility Dietary staff failed to consistently follow appropriate hand hygiene procedures for gloving and removal of soiled gloves and failed to wear effective hair restraint. This lack of hand hygiene failed to provide all patients in the facility with an aseptic environment to prevent the spread of contagious organisms. The facility census was 345.

Findings included:

Review of the "Infection Control Manual" dated 1985, and last revised in 2010, showed in part; on page 54 under Hand Hygiene, "Wash hands or use alcohol based hand sanitizer often and well, paying particular attention to around and under fingernails and between the fingers. Wash hands with soap and water before and after patient contact and whenever they are soiled with body substances."

Observation of medication administration on 01/19/11 at 8:28 AM, showed licensed practical nurse, Staff SSSS administer medication to a patient on the psychiatric services unit 3 South. After the medication administration Staff SSSS did not wash his/her hands or use hand sanitizer and then administered medication to Patient #1 at 8:31 AM. Staff SSSS continued to administer medications to Patients #2, #25, #26, and #8 without washing his/her hands or cleaning them with hand sanitizer between patients.

Observation on 01/19/11 at 8:50 AM, showed Staff SSSS open a locked medication cabinet, touch several envelopes containing home medications for patients, remove one envelope, close and lock the cabinet and continue to administer medications to patients without washing his/her hands or using hand sanitizer.


27029

During an observation on 01/19/11 at 8:36 AM, in SICU (Surgical Intensive Care Unit) Staff CCC, Registered Nurse (RN) administered medication via intravenous (within the vein) fluid lines. Staff CCC performed hand hygiene upon entering the room, donned gloves, then removed the gloves without performing hand hygiene. Staff CCC continued to do patient care and did not perform hand hygiene until exiting the patient's (#39) room.
During an observation on 01/19/11 at 10:00 AM, in CICU (Cardiac Intensive Care Unit), Staff DDD, RN, entered the room of Patient #41 and performed hand hygiene. Staff DDD donned gloves and performed a dressing change, then changed gloves from the dirty bandage to the clean bandage, but did not perform hand hygiene between the glove changes.
During an interview on 01/19/11 at 10:17 AM, with RN Staff PP, Director of SICU and RN Staff QQ, Director of Nursing stated the expectations were that hand hygiene would be completed between glove changes.
During an observation on 01/19/11 at 3:34 PM, in BICU (Intensive Care Burn Unit) Staff FFF, RN entered Patient #49's room to perform wound care. Staff FFF donned gloves and removed the soiled bandages (Stage 4 wounds on both legs) and removed the gloves, but did not perform hand hygiene. Staff FFF then administered pain medication to the patient, donned clean gloves and placed clean bandages on the patient's legs without performing hand hygiene between glove changes.
During an observation on 01/19/11 at 4:22 PM, of ostomy (surgical procedure creating an opening in the body for the discharge of body wastes) care for Patient #49, the facility Skin Care Team, Staff AAA, RN, and Staff BBB, RN entered the room and performed hand hygiene. Staff BBB changed gloves at three different intervals during the wound care, but did not perform hand hygiene between any of the glove changes. The Skin Care Team (Staff AAA and BBB) are designated to assess and perform wound care on all patients in the facility.
During an observation on 01/24/11 at 2:00 PM, in the Hemodialysis Unit (commonly referred to as dialysis and is a medical process used when a person's kidneys are damaged and can no longer filter toxins from the blood using a machine that pumps blood out of the patient, through a filtering machine and back into the patient). Staff PPP, RN was caring for Patient #74 during dialysis treatment and Staff PPP did not perform hand hygiene before approaching patient with medical supplies. Staff PPP then donned gloves and performed direct patient (#74) care, removed gloves and did not perform hand hygiene. Staff PPP then went to the water room (a room adjacent to dialysis unit that stores large water treatment tanks), he/she then left the Dialysis Unit and walked into the hall, returned to the Dialysis Unit and began direct patient (#75) care - all of these events were performed without hand hygiene.


13695

Observation on 01/19/11 at 11:05 AM, showed Physician/Anesthesiologist, Staff UUU entered Patient #20's room. Staff UUU stated he/she did not like the IV access that had been previously started. Staff UUU donned gloves then left the room wearing the gloves. Staff UUU returned to the room wearing gloves and carrying supplies to start a second IV access. Staff UUU then started a new IV access, removed his/her gloves and left the room.


16215

Record review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code directed in part the following:
-Chapter 2-301.14 Food handlers should wash hands before donning gloves and after engaging in activities that contaminate the hands.
-Chapter 2-402.11 Food handlers should wear effective hair restraints including beard restraints to keep hair from exposed foods, clean equipment and utensils.
-Chapter 3-304 Food handlers should wear single use gloves for one task and discard when damaged soiled or when interruptions occur in the operation.

Observation on 01/19/11 at 9:24 AM, in the Ellis Fischell campus kitchen showed Cook, Staff UUUU handled food preparation utensils and failed to cover a full beard with an effective hair restraint.

Observation on 01/19/11 at 10:30 AM, in the Women's and Children's campus kitchen showed the following:
-Diet Supervisor, Staff WWWW failed to wear an effective hair restraint over facial hair.
-Cook, Staff YYYY failed to wear an effective hair restraint over facial hair.

Observation on 01/19/11 at 10:42 AM, in the Women's and Children's campus kitchen showed Diet Aide, Staff XXXX failed to wash hands, donned gloves and prepared a patient meal tray. Further observation showed Staff XXXX touched his/her apron, handled a marking pen and failed to remove soiled gloves and wash hands before handling foods for patient meal service.

Observations on 01/21/11 from 7:49 AM through 8:43 AM, showed dietary staff at the main campus failed to wash hands and inconsistently used alcohol gel sanitizer after removing soiled gloves during the following:
-At 8:00 AM, Diet Aide, Staff ZZZZ and Diet Aide, Staff AAAAA donned gloves without hand washing and handled foods for patient meal service.
-At 8:06 AM, Staff AAAAA swiped a hand across his/her nose then, without hand washing or use of alcohol gel sanitizer, donned gloves and delivered meal trays to patients.
-At 8:11 AM, Staff AAAAA and Staff ZZZZ donned gloves without using alcohol gel sanitizer then handled patient meal trays.
-At 8:21 AM, Staff AAAAA donned gloves without hand washing or use of alcohol gel hand sanitizer then served a patient meal tray.
-At 8:31 AM, Staff AAAAA touched the side of his/her nose then, without hand washing or use of alcohol gel sanitizer donned gloves and served a patient meal tray.


14331

During interviews on 01/21/11 at 10:30 AM and 1:30 PM, Infection Control Practitioner, Staff BBBBB stated the following:
-Hand hygiene would be expected and appropriate after removal of gloves,
-Infection Control Practitioners do not routinely conduct hand hygiene surveillance in the dietary department,
-Infection Control Practitioners do observe for hand hygiene in the kitchen during quarterly environmental rounds,
-Infection Control Practitioners conduct in-services for the dietary department as requested.